From the Guidelines
The diagnostic approach for nausea and vomiting without abdominal pain should start with a careful history to understand the patient's symptoms, differentiating vomiting from regurgitation, rumination, and bulimia, and identifying any associated symptoms 1.
Key Steps in Diagnosis
- A thorough physical examination should be performed to identify any consequences or complications of vomiting and to look for signs that may point to the cause of the symptoms 1.
- Laboratory tests may be ordered to check for possible causes such as hypercalcemia, opioid use, or medication side effects, including blood levels of medications like digoxin, phenytoin, carbamazepine, and tricyclic antidepressants 2.
- Gastric emptying scintigraphy may be considered if gastroparesis is suspected, as it is the best accepted method to test for delayed gastric emptying 1.
Considerations
- The differential diagnosis of nausea and vomiting is extensive and includes a broad range of pathologic and physiologic conditions affecting the gastrointestinal tract, the central nervous system, and endocrine/metabolic functions 1.
- Medication review is crucial, as many medications can cause nausea and vomiting, and adjusting or changing medications may be necessary 2.
- If a specific cause is identified, targeted treatment should be initiated, such as proton pump inhibitors or histamine-2 (H2) receptor antagonists for gastritis or gastroesophageal reflux, or corticosteroids for gastric outlet obstruction 2.
From the Research
Diagnostic Approach
The diagnostic approach for nausea and vomiting without abdominal pain involves a comprehensive clinical history and physical examination to guide further diagnostic work-up 3. The following steps can be taken:
- Define what the patient means by nausea and vomiting, and determine whether symptoms are acute or chronic 4
- Consider medication or toxin adverse effects, and use the patient's presentation, severity of symptoms, and physical examination findings to formulate a differential diagnosis and to guide evaluation 4
- Direct treatment on the basis of knowledge of neurotransmitters and receptors involved in the emetic pathways 4
- For acute nausea and vomiting, management of symptoms may involve an empirical trial of antiemetics without extensive testing 4, 5
- For chronic nausea and vomiting, testing for an underlying cause should be performed, and medication adverse effects, neurologic causes, gastrointestinal diseases, metabolic or endocrine conditions, and psychogenic disorders should be considered in particular 4, 3, 5, 6, 7
Evaluation and Testing
Evaluation and testing for nausea and vomiting without abdominal pain may include:
- Basic laboratory testing such as urinalysis, urine pregnancy testing, complete blood count, comprehensive metabolic panel, amylase and lipase levels, thyroid-stimulating hormone level, and stool studies with cultures 7
- Imaging studies such as abdominal radiography, ultrasonography, and computed tomography 7
- Computed tomography of the head if an acute intracranial process is suspected 7
- Esophagogastroduodenoscopy for patients with risk factors for gastric malignancies or alarm symptoms 7
- Gastric emptying study if gastroparesis is suspected 7
Differential Diagnosis
The differential diagnosis for nausea and vomiting without abdominal pain is broad and may include:
- Gastrointestinal causes such as gastroenteritis, foodborne illness, and functional gastrointestinal disorders 4, 3, 5, 6, 7
- Neurologic causes such as migraine headaches, vestibular disturbances, and central nervous system disorders 4, 3, 5, 6, 7
- Metabolic and endocrine conditions such as pregnancy, thyroid disorders, and adrenal insufficiency 4, 3, 5, 6, 7
- Psychiatric causes such as anxiety, depression, and eating disorders 4, 3, 5, 6, 7
- Medication and toxin adverse effects 4, 3, 5, 6, 7